Lectures in periodontics – 4th stage
Classification of Perio. diseases – Part 1
Assist. Lec. Fahad M. al Dabbagh
Importance of disease classification:
1-Improved our understanding of the etiology and pathology of the diseases of the periodontium.
2-Disease classifications are useful for the purpose of diagnosis, prognosis, and treatment planning.
Classification of periodontal diseases:
1-Gingival diseases:
- Plaque induced gingival diseases.
- Non plaque induced gingival lesions.
2-Chronic periodontitis:
- Localized.
- Generalized.
3-Aggressive periodontitis:
- Localized.
- Generalized.
4-Periodontitis as a manifestation of systemic diseases.
5-Necrotizing periodontal diseases:
- Necrotizing ulcerative gingivitis.
- Necrotizing ulcerative periodontitis.
6-Abscess of periodontium:
- Gingival abscess.
- Periodontal abscess.
- Pericoronal abscess.
7-Periodontitis associated with endodontic lesions:
- Endodontic-periodontal lesion.
- Periodontal –endodontic lesion.
- Combined lesion.
8-Developmental and acquired deformities and conditions:
- Localized tooth related factors that predispose to plaque induced gingival diseases or periodontitis.
- Mucogingival deformities and conditions around teeth.
- Mucogingival deformities and conditions on edentulous ridges.
- Occlusal trauma.
- Gingival diseases:
- Plaque induced gingival diseases:
Gingivitis characterized by:
1-Presence of clinical signs of inflammation that are confined to the gingiva and associated with no attachment loss.
2-Gingivitis also has been observed to affect the gingiva of periodontitis-affected teeth that have previously lost attachment.
A.1. Gingivitis associated with dental plaque only:
-It is the result of an interaction between the microorganisms found in the dental plaque biofilm and the tissues and inflammatory cells of the host.
-The plaque-host interaction can be altered by the effects of local factors, systemic factors, or both; medications; and malnutrition that can influence the severity and duration of the response.
A.2. Gingival Diseases Modified by Systemic Factors
- Systemic factors contributing to gingivitis, such as the:
Endocrine changes associated with puberty,
the menstrual cycle,
Pregnancy,
Diabetes,
- These conditions exacerbated the gingival problem because of alterations in the gingival inflammatory response to plaque. This appears to be caused by the effects of the systemic conditions on the cellular and immunologic functions of the host.
- These changes are most apparent during pregnancy, when the prevalence and severity of gingival inflammation may increase even in the presence of low levels of plaque.
- Blood dyscrasias such as leukemia may alter immune function by disturbing the normal balance of immunologically competent white blood cells supplying the periodontium. Gingival enlargement and bleeding are common findings and may be associated with swollen, spongy gingival tissues caused by excessive infiltration of blood cells.
A.3. Gingival Diseases Modified by Medications:
- Gingival diseases modified by medications are increasingly prevalent because of the increased use of:
Anticonvulsant drugs known to induce gingival enlargement, such as phenytoin,
immunosuppressive drugs such as cyclosporine A,
Calcium channel blockers such as nifedipine, verapamil, diltiazem, and sodium valproate.
The development and severity of gingival enlargement in response to medications is patient specific and may be influenced by uncontrolled plaque accumulation.
The increased use of oral contraceptives by premenopausal women has been associated with a higher incidence of gingival inflammation and development of gingival enlargement that may be reversed by discontinuation of the oral contraceptive.
A.4. Gingival Diseases Modified by Malnutrition:
- Gingival diseases modified by malnutrition have received attention because of clinical descriptions of bright red, swollen, and bleeding gingiva associated with severe ascorbic acid (vitamin C) deficiency or scurvy.
- Nutritional deficiencies are known to affect immune function and may have an impact on the host's ability to protect itself against some of the detrimental effects of cellular products such as oxygen radicals.
B- Non-Plaque-Induced Gingival Lesions
-Oral manifestations of systemic conditions that produce lesions in the tissues of the periodontium are rare.
-They are observed in lower socioeconomic groups, developing countries, and immune compromised individuals.
B.1. Gingival Diseases of Specific Bacterial Origin:
- Gingival diseases of specific bacterial origin are increasing in prevalence especially as a result of sexually transmitted diseases such as gonorrhea (Neisseria gonorrhoeae) and to a lesser degree, syphilis (Treponemapallidum).
- Oral lesions may be secondary to systemic infection or may occur through direct infection.
- Streptococcal gingivitis or gingiva-stomatitis also is a rare condition that may present as:
An acute condition with fever, malaise, and pain associated with acutely inflamed, diffuse, red, and swollen gingiva with increased bleeding and occasional gingival abscess formation.
The gingival infections usually are preceded by tonsillitis.
It is associated with group a ß-hemolytic streptococcal infections.
B.2. Gingival Diseases of Viral Origin:
- Gingival diseases of viral origin may be caused by a variety of deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) viruses,
- Herpes viruses are the most common causative factors.
- Lesions are frequently related to reactivation of latent viruses, especially as a result of reduced immune function.
B.3. Gingival Diseases of Fungal Origin:
- Gingival diseases of fungal origin are relatively uncommon in the immune competent individual but occur more frequently in individuals who are immune compromised or in whom the normal oral flora has been disturbed by the long-term use of broad-spectrum antibiotics.
- The most common oral fungal infection is candidiasis caused by infection with Candida albicans, which can be seen under prosthetic devices, in individuals using topical steroids, and in individuals with decreased salivary flow, increased salivary glucose, or decreased salivary pH.
- A generalized candidal infection may manifest as white patches on the gingiva, tongue, or oral mucous membrane that can be removed with gauze, leaving a red, bleeding surface.
- In HIV-infected individuals, candidal infection may present as erythema of the attached gingiva and has been referred to as linear gingival erythema or HIV-associated gingivitis.
- Diagnosis of candidal infection can be made by culture, smear, and biopsy.
B.4. Gingival Diseases of Genetic Origin:
- Gingival diseases of genetic origin may involve the tissuesof the periodontium.
- Hereditary gingival fibromatosisis one of the most clinically evident conditions that exhibit autosomal dominant or (rarely) autosomal recessive modes of inheritance. The gingival enlargement may completely cover the teeth, delay eruption, and present as an isolated finding or be associated with several more generalized syndromes.
B.5. Gingival Manifestations of Systemic Conditions:
- Gingival manifestations of systemic conditions may appear as desquamative lesions, ulceration of the gingiva, or both.
- Allergic reactions that manifest with gingival changes are uncommon but have been observed in association with several restorative materials, toothpastes, mouthwashes, chewing gum, and foods.
B.6. Traumatic Lesions:
Traumatic lesions may be factitial (produced by artificial means; unintentionally produced) as in:
toothbrush trauma resulting in gingival ulceration, recession or both;
Iatrogenic (trauma to the gingiva induced by the dentist or health professional) as in the case of preventive or restorative care that may lead to traumatic injury of the gingiva;
Accidental as in the case of damage to the gingiva through minor burns from hot foods and drinks.
B.7. Foreign Body Reactions:
- Foreign body reactions lead to localized inflammatory conditions of the gingiva and are caused by the introduction of foreign material into the gingival connective tissues through breaks in the epithelium.
- Common examples are the introduction of amalgam into the gingiva during the placement of a restoration or extraction of a tooth, leaving an amalgam tattoo, or the introduction of abrasives during polishing procedures.